the Childcare Specialist Application

6203 S. Lemay • Fort Collins, CO 80525• phone 970.207.9435 • www.respitecareinc.org
*Please attach your cover letter, resume, and unofficial transcripts
*Return to Lyndsi Hrubes-Staff Manager- [email protected]
Child Care Specialist Application
Date: ________________
PERSONAL INFORMATION:
Name: ______________________________________ Are you 18 years or older?____________________________
Present Address: __________________________________________________________________________________
Street
City
State
Zip
Permanent Address: _______________________________________________________________________________
Street
City
State
Zip
Phone #: (H)____________________________ (W)_________________________ (C)_______________________
Permanent Phone #: (H)____________________________
E-mail address: ___________________________________________________________________________
Referred by: ______________________________________________________________________________
Available Starting Date: ___________________________ Full-time? _____________ Part-time? ______________
Are you currently employed? ______________________ Full-time? _____________ Part-time? ______________
If yes, where? __________________________________________________________________________________
May we contact your present employer? Yes________
No_________
Have you ever applied for a position at Respite Care in the past? Yes ____ No ____ If yes, when ____________
In the space below please give us some idea of the times you are available to work, also, please fill in other
commitments such as school schedule, work, etc.:
Available days and times
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Other Commitments (school schedule – please attach copy of official class schedule)
Monday
Tuesday
Wednesday
Thursday
1
Friday
Saturday
Sunday
Number of hours available per week: _____________ Maximum _______________ Minimum
EDUCATION AND TRAINING:
NAME & LOCATION
OF SCHOOL
DATES ATTENDED
GRADUATION DATE
MAJOR FOCUS
HIGH
SCHOOL
COLLEGE
(If hired, please be prepared to supply a copy of your college transcripts)
Subjects of Special Study or Research Work: __________________________________________________________
__________________________________________________________________________________________________
All potential employees must be certified in Infant/Child/Adult CPR, First Aid and Universal Precautions prior to
employment, if not certified employee must be willing to become certified. Respite Care offers classes on premise.
Are you certified in Infant/Child CPR?
Yes_______
No_______
exp. date______________
Are you certified in Adult CPR?
Yes_______
No_______
exp. date______________
Are you certified in Standard First Aid?
Yes_______
No_______
exp. date______________
Are you certified in Universal Precautions?
Yes_______ No_______
exp. date______________
Do you have your early childhood teacher qualification? Yes_______
No_______
exp. date______________
WORK EXPERIENCE:
(Most recent first)
1. Employer_______________________________________________ Job Title______________________________
Dates Employed____________________ to ___________________ Hours per week: _______________________
Address________________________________________ City___________________ State________ Zip_________
Phone______________________ Job Title____________________________ Supervisor_______________________
Starting Salary___________________________________
Ending Salary__________________________________
Duties Performed ________________________________________________________________________________
Reason for Leaving _______________________________________________________________________________
2. Employer_______________________________________________ Job Title______________________________
Dates Employed____________________ to ___________________ Hours per week: _______________________
Address________________________________________ City___________________ State________ Zip_________
Phone______________________ Job Title____________________________ Supervisor_______________________
Starting Salary___________________________________
Ending Salary__________________________________
Duties Performed ________________________________________________________________________________
Reason for Leaving _______________________________________________________________________________
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3. Employer_______________________________________________ Job Title______________________________
Dates Employed____________________ to ___________________ Hours per week: _______________________
Address________________________________________ City___________________ State________ Zip_________
Phone______________________ Job Title____________________________ Supervisor_______________________
Starting Salary___________________________________
Ending Salary__________________________________
Duties Performed ________________________________________________________________________________
Reason for Leaving _______________________________________________________________________________
Have you ever been involuntarily terminated or asked to resign from any position of employment?
Yes ________ No ______
If yes, please describe circumstances: ______________________________________________________________
_______________________________________________________________________________________________
Briefly describe experiences you have had working with persons with disabilities: _______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please explain briefly your reasons for wanting to work as a Respite Care Child Care Specialist:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have any physical conditions or restrictions that may limit your ability to perform the job applied for?
(Please see job description for physical requirements of the job)
Yes_______ No_______
If yes, please explain: ___________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Have you ever been arrested, convicted of a misdemeanor or felony, or have a current criminal charge
pending?
Yes_______ No_______
If yes, please explain: ___________________________________________________________________________
_______________________________________________________________________________________________
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In case of an emergency, please notify:
1. _______________________________________________________________________________________
Name
Address
Phone #
Relationship: __________________________________
2. _______________________________________________________________________________________
Name
Address
Phone #
Relationship: __________________________________
REFERENCES:
List three references not related to you (include at least one previous employer). Please give consideration to
your references since all will be contacted and asked to complete a short questionnaire.
1.
______________________________________________________________________________________
Name
2.
Phone
Relationship
Years Known
______________________________________________________________________________________
Name
3.
Address, Zip
Address, Zip
Phone
Relationship
Years Known
______________________________________________________________________________________
Name
Address, Zip
Phone
Relationship
Years Known
PLEASE READ CAREFULLY BEFORE SIGNING
Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty
of perjury in the second degree as defined in Section 18-8-503, C.R.S., and, upon conviction thereof, shall be punished
accordingly. I understand that false information may be grounds for not hiring me or for immediate termination of
employment at any point in the future if I am hired.
I authorize the verification of any or all information listed above.
In accordance with State and Federal Laws, Respite Care, Inc. is required to complete a criminal background check. I
understand that my employment is conditional upon receiving a favorable response.
Should I be employed by Respite Care, Inc., I agree to undergo and satisfactorily pass a medical examination prior to
employment at my expense.
I have read the Child Care Specialist job description and understand the general responsibilities and policy.
_______________________________________________________
Signature
RESPITE CARE, INC. IS AN EQUAL OPPORTUNITY EMPLOYER
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__________________
Date